01/01/2013

Imaging of the Right Ventricle

Case presentation
Echo views to assess RV
Review of ASE guidelines on the
right heart
Practical approach to assess RV
Lessons from the case

46 year old woman has a long history

of tiredness and exertional dyspnea.
She has LV dysfunction and
1. Dilated RV (mild, moderate, severe).
2. RV systolic dysfunction (mild,
moderate, severe).
3. TR (mild, moderate, severe).
4. Intrinsic RV dysfunction versus
secondary to LV dysfunction.
5. The underlying etiology.

01/01/2013

46 y old woman with tiredness and dyspnea

RV diastolic and systolic areas

and FAC

01/01/2013

Right Ventricle
Neglected
compared to LV.
Primary diseases of
RV are uncommon.
RV dysfunction is
present in many
conditions.
RV dysfunction can
have incremental
prognostic value.

01/01/2013

Causes of Right Ventricular Failure

Intrinsic myocardial disease

Pressure overload

RV ischemia or infarction

LV failure

Cardiomyopathies ARVC,
dilated, hypertrophic, infiltrative

Mitral valve disease

RV dysplasia

Pulmonary veno-occlusive
disease
Pulmonary artery hypertension

Volume overload
Atrial septal defect
Anomalous pulmonary venous
return

Pulmonary hypertension due to

pulmonary diseases
Pulmonary stenosis
Pulmonary arterial stenosis

Pulmonary regurgitation
Tricuspid regurgitation

Limitation to RV filling
Tricuspid stenosis
Tamponade
Pericardial constriction

RV Assessment by Echo
Guidelines for the echocardiographic
assessment of the right heart in
adults: a report of the American
Society of Echocardiography.
JASE, 2010.

The echocardiographic assessment

of the right ventricle: what to do in
2010?
Eur J Echo, 2010

01/01/2013

RV Assessment by Echo
Complex geometry
with distinct inlet and
outlet portions.
Thin wall with heavy
trabeculations.
Not suited for simple
geometric models.
Any single linear
measurement may be
misleading.

Graphic Representation of the Echocardiographic

Views Used for Evaluating the Right Ventricle

Jurcut R et al. Eur J Echocardiogr 2010;11:81-96

01/01/2013

Imaging Views

Specific Measurements

Parasternal long-axis

End-diastolic RVOT diameter

RV inflow view

Anatomy and function of tricuspid valve

RV outflow view

Anatomy and function of pulmonary valve

Parasternal RV short-axis views

End-diastolic and end-systolic diameters of RVOT

RVOT shortening fraction
RV size and function
RV volume by off-line reconstruction

Parasternal LV short-axis views

LV eccentricity index

Apical four-chamber view

RV size and function

RV long- and short-axis diameters
RV fractional area change
RV annular TDI
RV strain and strain rate
RV myocardial performance index
Anatomy and function of tricuspid valve
3D RV volume and ejection fraction

Subcostal view

RVOT size and obstruction

RV free wall thickness

Modified from Jurcut , 2010

Apical 4-chamber view

with focus on RV

01/01/2013

RV dimensions and FAC

RV basal
diameter 2.9cm

FAC=55%

Parasternal RV focused views

01/01/2013

TV annular systolic excursion and

velocities

TAPSE=33mm
TAPSE=
TAPSE=

S=16.9cm/s

RV index of myocardial
performance

01/01/2013

RV longitudinal stain

3D RV volumes and EF

01/01/2013

Pulmonary Vascular Resistance

pressure = flow x resistance.
High systolic PA pressure increase
in pulmonary vascular resistance.
PVR (wood units) = 10 x TRv + 0.16
RVOTTVI
Provides insight into etiology of RV
dysfunction.

Reference Limits for Measures of

RV Structure and Function
Abnormal
Chamber Dimension
RV basal diameter, cm
RV end-diastolic area, cm2
RV subcostal wall thickness, cm
RVOT PSAX diameter, cm
RVOT PLAX diameter, cm

> 4.2
> 25
> 0.5
> 2.7
> 3.3

Systolic function
TAPSE, cm
Annular S cm/s
Pulsed Doppler RIMP
Tissue Doppler RIMP
FAC, %

< 16
< 10
> 0.40
>0.55
< 35
Modified from Rudski, JASE 2010

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01/01/2013

Assessment of RV Size and Function

Retrospective study of 12 patients (age 5219
years, 6 women) who had echo and CMR within
24 hours
5 patients had 3-4+ TR, and 2 had 3-4+ PR
15 readers graded RV size and function by visual
assessment based on RV views
Followed by brief presentation and distribution
of the RV guidelines
Second reading 2 weeks later by same readers on
same views, but now included additional images
with measurements of RV dimension, RVOT, FAC,
S, TAPSE and RIMP
Ling et al, JASE 2012

Accuracy of Echo Assessment of

RV size and function
Sensitivity Specificity

RV size
Visual
Visual + measurements

87%
98%

38%
78%

0.40
0.77

80%
92%

52%
84%

0.43
0.66

RV function
Visual
Visual + measurements

Ling JASE 2012

11

01/01/2013

Practical approach to assess

RV size

Kurtz, 2012

Practical approach to assess

RV systolic function

Kurtz, 2012

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01/01/2013

46 year old woman has a long history

of tiredness and exertional dyspnea.
She has LV dysfunction and
1. Dilated RV (mild, moderate, severe).
2. RV systolic dysfunction (mild,
moderate, severe).
3. TR (mild, moderate, severe).
4. Intrinsic RV dysfunction versus
secondary to LV dysfunction.
5. The underlying etiology.

46 y old woman with tiredness and dyspnea

13

01/01/2013

46 y old woman with tiredness and dyspnea

IVC=3.2cm

RV focused apical 4-chamber view

14

01/01/2013

Quantitative RV Measurements
Ref Value
RV Dimension
RVED area (cm2)
Basal diameter (cm)
Wall thickness (cm)

39.7
5.2
0.36

<25
<4.2
<0.5

RV function
TAPSE (cm)
Annular S (cm/s)
RIMP
FAC

1.5
7.7
0.96
25

>16
>10
<0.55
>35

Hemodynamics
SPAP (mmHg)
PVR (WU)

21
1.78

<35
<2.0

15

01/01/2013

46 year old woman has a long history

of tiredness and exertional dyspnea.
She has LV dysfunction and
1. Dilated RV (mild, moderate, severe).
2. RV systolic dysfunction (mild,
moderate, severe).
3. TR (mild, moderate, severe).
4. Intrinsic RV dysfunction versus
secondary to LV dysfunction.
5. The underlying etiology.

Echo Assessment of RV

Beware of RV dysfunction.
Exploit RV focused views.
Incorporate RV quantitative measures.
Ease of use measures include TAPSE, S,
RVEDD and FAC.
SPAP does not equate PVR.
3D RV volumes and EF appear promising.

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